Corrective Action Plans

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View of Responsible Official: Management agrees with the Finding. During the last fiscal year, the Executive Director consulted with other public housing agencies in the region and learned that many rely on the firm Nelrod to accurately identify and validate the supporting data used to establish uti...
View of Responsible Official: Management agrees with the Finding. During the last fiscal year, the Executive Director consulted with other public housing agencies in the region and learned that many rely on the firm Nelrod to accurately identify and validate the supporting data used to establish utility allowances. Nelrod conducts a comprehensive Utility Allowance Survey and Study, which provides the detailed analysis needed to develop a more reliable Utility Allowance Table for the applicable fiscal year. Based on this information, we have adopted a policy to contract with Nelrod to prepare the Utility Allowance Study beginning in fiscal year 2025–2026
View of Responsible Official: Management agrees with the Finding. To support long term sustainability, administrative fees are reviewed on a biweekly basis to identify opportunities for cost reduction or absorption while the program continues to stabilize and grow. These measures are intended to ens...
View of Responsible Official: Management agrees with the Finding. To support long term sustainability, administrative fees are reviewed on a biweekly basis to identify opportunities for cost reduction or absorption while the program continues to stabilize and grow. These measures are intended to ensure that the program remains compliant, financially sound, and operationally viable on an annual basis
Finding 2025-002 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities’ internal controls did not operate as designed, which resulted in rent reasonableness tests not being reviewed befor...
Finding 2025-002 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities’ internal controls did not operate as designed, which resulted in rent reasonableness tests not being reviewed before the rent was paid. Corrective Action Plan: The Senior Division Director (now VP of Housing) issued the Rent Reasonableness Policy (Scattered Sites) on May 14, 2025. This policy was approved by the CEO on June 3, 2025, and was disseminated to all applicable staff via the Learning Management System (Bridge). Staff are required to read and electronically sign acknowledgement of every policy sent to them via Bridge. Managers in the Scattered Site program were trained on the policy and procedure in July 2025. To ensure compliance with this policy, the VP of Housing will audit all client files at least twice annually. The first audit is scheduled for March 11, 2026. Results of the internal audit will be shared with the Compliance Department for further assessment and action. Responsible Individuals: Kristen Brown, Vice-President of Housing Anticipated Completion Date: March 31, 2026
Finding 2025-007: Reporting Material Weakness/Noncompliance Special Tests and Provisions Management agrees with this finding. The required owner certified annual financial report for the Section 202 Capital Advance Program was not submitted to HUD within 90 days of fiscal year end because year end f...
Finding 2025-007: Reporting Material Weakness/Noncompliance Special Tests and Provisions Management agrees with this finding. The required owner certified annual financial report for the Section 202 Capital Advance Program was not submitted to HUD within 90 days of fiscal year end because year end financial records were not completed in time. To prevent this from happening again, management will establish a simple year end reporting calendar, assign responsibility to a designated staff member to track HUD deadlines, and work more closely with the fee accountant to ensure financial information is completed earlier and ready for timely submission. These procedures will be in place for the next fiscal year end reporting cycle.
Finding 2025-006: Replacement Reserves Material Weakness/Noncompliance LHA agrees with this finding. While monthly replacement reserve reconciliations were being completed and reviewed, the review focused on making sure the ending balance matched and did not include a detailed review of the activity...
Finding 2025-006: Replacement Reserves Material Weakness/Noncompliance LHA agrees with this finding. While monthly replacement reserve reconciliations were being completed and reviewed, the review focused on making sure the ending balance matched and did not include a detailed review of the activity in the account. Because of this, multiple deposits were made in some months without being noticed. One replacement reserve payment was also mistakenly deposited into another program’s replacement reserve account. Although the fee accountant properly recorded this as money due back to Eastlawn East, staff did not identify that the funds had not yet been returned as of June 30, 2025. In addition, we were unable to locate documentation showing HUD approval for a $13,329.48 replacement reserve withdrawal. We understand that HUD approval is required for all withdrawals and that documentation should be maintained. To address this issue and prevent it from happening again we are updating procedures as follows Replacement Reserves: A spreadsheet is being made for each month for each account. LHA will keep track of the date each deposit for the Eastlawn and Eastlawn East Accounts are made and verify by a second party (one that does not do the deposit) that they are being placed in the correct account. Management will perform an additional review of replacement reserve activity each month. We are working with the other program to ensure the misapplied funds are returned to Eastlawn East. We will contact HUD to determine the appropriate next steps regarding the withdrawal without approval documentation and will ensure all future approvals are properly retained.
Corrective Action: The Housing Authority will implement a targeted Quality Control (QC) review process under the oversight of the Housing Operations Director to ensure utility allowances are calculated, documented, and applied in accordance with HUD requirements, the Authority's approved utility all...
Corrective Action: The Housing Authority will implement a targeted Quality Control (QC) review process under the oversight of the Housing Operations Director to ensure utility allowances are calculated, documented, and applied in accordance with HUD requirements, the Authority's approved utility allowance schedule, and HUD Form 52667. The QC process will ensure that the lower of the approved voucher bedroom size or the actual unit bedroom size is consistently applied. Implementation: • The Housing Operations Director will oversee selective QC reviews of key HCV transactions, including: o New admissions o Selected annual reexaminations o Selected interim reexaminations impacting rent or utility allowances o Selected Housing Assistance Payment (HAP) contracts prior to approval • Reviews will verify: o Correct bedroom size determination o Accurate utility allowance calculations o Proper system entry and supporting documentation maintained in the tenant file and HAP registry • Management will review and correct the tenant files identified in the audit sample and document revised calculations as needed. • A standardized utility allowance calculation worksheet will be required in tenant files. • Staff will receive refresher training on utility allowance calculation and documentation requirements. • Periodic internal monitoring will be conducted to ensure ongoing compliance.
Finding Description: Per the VOCA contract, the grantee is required to submit quarterly fiscal and programmatic reports by the 15th calendar day of the month following the end of the quarter to the State of NJ. Testing of the compliance requirement indicated that several reports were not submitted t...
Finding Description: Per the VOCA contract, the grantee is required to submit quarterly fiscal and programmatic reports by the 15th calendar day of the month following the end of the quarter to the State of NJ. Testing of the compliance requirement indicated that several reports were not submitted timely. Corrective Action and Method of Implementation: The Organization is currently in a transition phase and plans to reorganize job duties and adjust staffing within the Finance Department to support the preparation and timely submission of quarterly fiscal and programmatic reports. These delays resulted from postponed contract approvals by the contracting entity, as well as staff turnover, which affected the timely filing of complete and accurate reports. Name of Responsible Person: Diane Hobbs, Chief Financial Officer Anticipated Completion Date: June 2026
Controls around fishing attacks have been implemented to ensure no inappropriate withdrawls are made from the reserve accounts.
Controls around fishing attacks have been implemented to ensure no inappropriate withdrawls are made from the reserve accounts.
Controls around fishing attacks have been implemented to ensure no inappropriate withdrawls are made from the reserve accounts.
Controls around fishing attacks have been implemented to ensure no inappropriate withdrawls are made from the reserve accounts.
MTW Income Verification and Rent Calculation Explanation of Condition: The Authority operates under HUD-approved MTW waivers, including three-year certifications. In the finding identified, Enterprise Income Verification (EIV) was not utilized during a Year 1 MTW income calculation, resulting in und...
MTW Income Verification and Rent Calculation Explanation of Condition: The Authority operates under HUD-approved MTW waivers, including three-year certifications. In the finding identified, Enterprise Income Verification (EIV) was not utilized during a Year 1 MTW income calculation, resulting in underreported income and an incorrect rent determination that carried forward into the second year of the MTW cycle. Corrective Actions Taken and Planned: To strengthen compliance with HUD occupancy requirements and MTW oversight standards, the Authority has implemented the following corrective actions:  The Authority has developed and implemented a formal Standard Operating Procedure (SOP) for MTW Income Verification and Rent Calculations, which requires: o Mandatory EIV review in accordance with HUD’s verification hierarchy o Documentation of EIV review in each tenant file o Supervisory review and approval of all MTW rent calculations  An internal quality control and audit review process has been established to periodically review rent calculations and certifications for accuracy and compliance.  The recertification process has been restructured so that MTW and annual recertifications are conducted primarily during April and May, allowing staff to focus on accurate income verification and calculations without competing operational demands.  Occupancy staff have received refresher training on MTW requirements, EIV usage, and HUD income verification standards.  The Authority plans to utilize MTW flexibility to implement a Standard Deduction, which will reduce calculation complexity, improve consistency, and minimize the likelihood of future errors. The Authority believes these corrective actions align with HUD monitoring expectations, strengthen internal controls, and demonstrate ongoing commitment to MTW compliance.
Name of auditee: Town of Plattsburgh Housing Development Fund Company, Inc. TIN: 014-EE068 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2025 CAP prepared by: David Kimmel President Two Plus Four Property Management Co,. Inc. (315) 437-2178 Current Finding on the S...
Name of auditee: Town of Plattsburgh Housing Development Fund Company, Inc. TIN: 014-EE068 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2025 CAP prepared by: David Kimmel President Two Plus Four Property Management Co,. Inc. (315) 437-2178 Current Finding on the Schedule of Findings and Questioned Costs and Recommendations Finding 2025-001 (a) Comments on the finding and recommendation: Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. (b) Action taken: Management has deposited the underfunded amount of $21,250 into the residual account on February 19, 2026.
Management concurs with the finding and notes that the Town is actively working to complete the integration of the payroll module within the new accounting platform. Management has arranged system training to ensure staff understand the payroll and reconciliation functions and can effectively utiliz...
Management concurs with the finding and notes that the Town is actively working to complete the integration of the payroll module within the new accounting platform. Management has arranged system training to ensure staff understand the payroll and reconciliation functions and can effectively utilize the module once configuration is complete. In the interim, the Town will continue to prepare timely reconciliations and record necessary adjusting entries to ensure accurate financial reporting.
Audit Finding 2025-001 - Funds were withdrawn from the reserve for replacement account to cover an operational shortfall and were withdrawn without HUD approval. Response: Management will refund the replacement reserve for the withdrawn funds as soon as excess operating cash becomes available. - Nam...
Audit Finding 2025-001 - Funds were withdrawn from the reserve for replacement account to cover an operational shortfall and were withdrawn without HUD approval. Response: Management will refund the replacement reserve for the withdrawn funds as soon as excess operating cash becomes available. - Name and Title of contact person responsible for corrective action: Linda Holder - Executive Director – Houston Housing Management Corporation - Fulton Gardens II - PO Box 1819 - Houston, TX 77002 - 713-526-9470
Approved expenditures of federal awards were not for the Project. Recommendation: CLA recommends enforcing control procedures over expenditures of federal awards. CLA also recommends performing an additional year-end review of accounts payable to confirm that expenditures are appropriately classifie...
Approved expenditures of federal awards were not for the Project. Recommendation: CLA recommends enforcing control procedures over expenditures of federal awards. CLA also recommends performing an additional year-end review of accounts payable to confirm that expenditures are appropriately classified and allocated to the correct sites. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management will recommunicate their policies and ensure proper controls over expenditures of federal awards are enforced. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: September 30, 2026
Eligibility for a resident was not supported. Recommendation: CLA recommends enforcing control procedures over resident eligibility. Explanation of disagreement with audit finding: Management identifies that the resident move-in was conducted by the prior management company. Action planned in respon...
Eligibility for a resident was not supported. Recommendation: CLA recommends enforcing control procedures over resident eligibility. Explanation of disagreement with audit finding: Management identifies that the resident move-in was conducted by the prior management company. Action planned in response to finding: During fiscal 2026, the management company will recommunicate their policies and ensure proper controls over eligibility are enforced. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: September 30, 2026
An ineligible resident was residing at the property. Recommendation: CLA recommends enforcing control procedures over resident eligibility. Explanation of disagreement with audit finding: Management identifies that the resident move-in was conducted by the prior management company. Action planned in...
An ineligible resident was residing at the property. Recommendation: CLA recommends enforcing control procedures over resident eligibility. Explanation of disagreement with audit finding: Management identifies that the resident move-in was conducted by the prior management company. Action planned in response to finding: During fiscal 2026, the management company will recommunicate their policies and ensure proper controls over eligibility are enforced. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: September 30, 2026
Reserve for replacement funds and project funds were not maintained in interest bearing bank accounts. Recommendation: CLA Recommends withdrawing the reserve for replacement funds and project funds and depositing the funds into interest bearing accounts. Explanation of disagreement with audit findin...
Reserve for replacement funds and project funds were not maintained in interest bearing bank accounts. Recommendation: CLA Recommends withdrawing the reserve for replacement funds and project funds and depositing the funds into interest bearing accounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: During fiscal 2026, the funds were deposited into interest bearing accounts. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: December 31, 2025
Deposits required by HUD were not made in full during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project make all fiscal year 2025 deposits as soon as funds allow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action pl...
Deposits required by HUD were not made in full during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project make all fiscal year 2025 deposits as soon as funds allow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: During fiscal 2026, the missing deposits were made. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: December 31, 2025
Finding Reference Number: 2025-001 Federal Program: Supportive Housing for the Elderly-Section 202 (Assistance Listing No. 14.157) Federal Award Agency: U.S. Department of Housing and Urban Development Name of contact person: Shannon McCandlish, Controller Manor Management Services of Alaska Correct...
Finding Reference Number: 2025-001 Federal Program: Supportive Housing for the Elderly-Section 202 (Assistance Listing No. 14.157) Federal Award Agency: U.S. Department of Housing and Urban Development Name of contact person: Shannon McCandlish, Controller Manor Management Services of Alaska Corrective Action: A tenant file containing three income sources were not supported by third party verification, as required by HUD. The on site manager understands and will be diligent in using internal checklists that would have identified the missing income verification documentation. Date of Planned Corrective Action : January 06, 2026
The Owner has ended the additional principal payments being paid to the mortgage company, effective August 2025. The Owner is also in the process of requesting authorization from the US Department of HUD to disburse $260,000 from residual receipts (the sum of the additional principal payments made o...
The Owner has ended the additional principal payments being paid to the mortgage company, effective August 2025. The Owner is also in the process of requesting authorization from the US Department of HUD to disburse $260,000 from residual receipts (the sum of the additional principal payments made on the mortgage from August 2024 - August 2025, without previous HUD approval) to reimburse the operating account for these disbursements.
Comments on the Finding and Each Recommendation The Property received a NSPIRE inspection dated August 1, 2024. The inspection resulted in a score of 59 (out of a possible 100). Scores below 60 are referred to the Departmental Enforcement Center. Management must maintain the Property in decent, safe...
Comments on the Finding and Each Recommendation The Property received a NSPIRE inspection dated August 1, 2024. The inspection resulted in a score of 59 (out of a possible 100). Scores below 60 are referred to the Departmental Enforcement Center. Management must maintain the Property in decent, safe, and sanitary condition and good repair. Management must respond to HUD in three days of receiving the inspection report and confirm all lifethreatening deficiencies have been corrected. Action(s) taken or planned on the finding Management and the Board of Directors concur with the finding and the auditor's recommendations. Management has responded to HUD in regard to this inspection report and on July 8, 2025 another inspection was conducted that resulted in a final score of 95 (out of a possible 100).
Finding 2025-001 - Housing Choice Voucher Tenant Files - Eligibility - Rent Calculations Noncompliance & Material Weakness Section 8 Housing Choice Voucher Program -ALNs #14.871 and #14.EHV Corrective Action Plan: Action Steps: • Separate responsibilities into two functions: eligibility/verification...
Finding 2025-001 - Housing Choice Voucher Tenant Files - Eligibility - Rent Calculations Noncompliance & Material Weakness Section 8 Housing Choice Voucher Program -ALNs #14.871 and #14.EHV Corrective Action Plan: Action Steps: • Separate responsibilities into two functions: eligibility/verification and rent calculation, assigning verification tasks to new staff and rent calculations to experienced staff. • Strengthen monitoring and evaluation of HCVP files to ensure accurate income projections and rent calculations. The Compliance Officer will conduct individual reviews of audit findings and resolve discrepancies. • Engage an external contractor to perform biannual audits on 10% of files. Findings will inform targeted staff training. • Implement monthly peer audits among Program Assistants to identify and correct errors collaboratively, fostering continuous learning. • Conduct monthly training sessions led by the Program Director to address recent discrepancies and promote team development. • Enforce disciplinary measures for underperformance: employees failing to achieve an 80% audit success rate for three consecutive months will enter a 90-day improvement plan. Person(s) Responsible: Shanae Golliday-Anderson, Program Director Pam Jackson, Deputy Director Anticipated Completion Date: June 30, 2026
Finding 2025-002 - Low Rent Public Housing Tenant Files - Eligibility - Rent Calculations Noncompliance & Significant Deficiency Low Rent Public Housing - ALN #14.850 Corrective Action Plan: Action Steps: • SCCHA will hire an industry consultant to evaluate its internal processes related to eligibil...
Finding 2025-002 - Low Rent Public Housing Tenant Files - Eligibility - Rent Calculations Noncompliance & Significant Deficiency Low Rent Public Housing - ALN #14.850 Corrective Action Plan: Action Steps: • SCCHA will hire an industry consultant to evaluate its internal processes related to eligibility and tenant rent calculations, with a focus on improving the accuracy of adjusted annual income computations. • An external contractor will conduct biannual audits on 10% of files, with results guiding targeted staff training initiatives. • The Compliance & Integrity Coordinator will review audited files and hold individual meetings with team members to address errors and clarify relevant procedures and policies. • Monthly peer-to-peer audits will be implemented, along with staff meetings to collectively analyze identify errors, fostering ongoing training and staff engagement. • Enforce disciplinary measures for underperformance: employees failing to achieve an 80% audit success rate for three consecutive months will enter a 90-day improvement plan. Person(s) Responsible: Meisha Kerby, Program Director Pam Jackson, Deputy Director Anticipated Completion Date: June 30, 2026
Management has addressed the issue by recertifying the tenant and does not expect late recertifications or income verification to occur again.
Management has addressed the issue by recertifying the tenant and does not expect late recertifications or income verification to occur again.
On November 4, 2025, UK HealthCare (UKHC) Information Technology implemented a system configuration change within Epic related to the NFV Sliding Scale settings. This change restricts the application of Federal Poverty Level (FPL) discounts to accounts with a status of “Approved for Financial Assist...
On November 4, 2025, UK HealthCare (UKHC) Information Technology implemented a system configuration change within Epic related to the NFV Sliding Scale settings. This change restricts the application of Federal Poverty Level (FPL) discounts to accounts with a status of “Approved for Financial Assistance,” thereby preventing discounts from being applied to accounts that have not been formally approved. In addition, on December 8, 2025, a new status option— “Did Not Apply for FA”—was added to the status field within the FPL table in Epic. This option is to be selected when patients do not apply for financial assistance, ensuring that status fields are never left incomplete or blank. NFVCHC staff were notified of this update and instructed to consistently complete this step. Planned Process Improvements:NFVCH leadership will conduct a comprehensive review of the NFV and JB clinic policies and procedures related to Financial Assistance Program (FAP) eligibility determination and reevaluation. This review will ensure that: FAP documentation does not include overlapping coverage periods Effective and termination dates are properly validated Internal processes align with system requirements and safeguard against data inconsistencies Ongoing Monitoring / Sustainability Plan: To strengthen oversight and ensure longterm control effectiveness, UKHC Enterprise Revenue Cycle will incorporate into its monthly audit procedures the following reviews: A report identifying accounts with blank or incomplete status entries on the Federal Poverty Level table A review of overlapping FPL coverage dates Monitoring for patients who have both UK and NFV Charity Care, ensuring the correct NFV FPL table is applied for NFVCH accounts This continuous monitoring will ensure system controls operate as designed and that corrective actions remain effective over time. Responsible Party: Larry Quillen – Executive Director, NFVCH Anne Wray - ERC Revenue Assurance Director/UKHC Target Completion Date: Completed on November 4, 2025, with additional enhancements on December 9, 2025
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